Notified cases of mpox in the city of Rio de Janeiro, Brazil: a descriptive study, 2022

Study contributions Main results The notified cases of mpox in the city of Rio de Janeiro were mainly concentrated in men aged 30 to 39 years. The majority presented a mild condition that progressed to cure without hospitalization. Implications for services The profile obtained can contribute to the targeting of local health care policies, targeting prevention and health promotion actions. Perspectives Additional investigations can contribute to expanding knowledge of the disease. Investment in health surveillance is necessary to respond to public health emergencies.


INTRODUCTION
Mpox is a zoonotic viral disease with an average incubation period of 6 to 16 days, the reservoir of which is unknown. 1 The first cases were associated with hunting and eating infected wild animals, 2 although its transmission also occurs between people or through contact with infected material. 3,4he most common signs and symptoms of the disease are skin lesions, headache, fever, myalgia, fatigue and lymph node enlargement, 5 and transmission ends once the lesions have disappeared.Most cases have mild clinical manifestations and have good prognosis, however, in immunosuppressed individuals, the condition may worsen and require hospitalization. 4ox is an abbreviation for monkeypox, as it was identified in a non-human primate in 1958. 3In 1970, the first case in humans was identif ied in the Democratic Republic of the Congo, 2 with outbreaks occurring in the 1970s and 1980s in that republic and in other countries in the West and Central Africa. 3In recent years, there has been an increase in the incidence rate from 0.72 cases per 100,000 inhabitants, in 1980, to 14.4 cases/100,000 inhab. in 2000, on the African continent. 3In 2003, the United States had its first outbreak of mpoxs 6 and, in 2017 and 2018, there were outbreaks in Nigeria and Cameroon, where there had been no recorded cases for two decades. 3From May to July 2022, more than 16,000 cases of mpox were reported in 75 countries, 7 with the World Health Organization (WHO) declaring a Public Health Emergency of International Concern in relation to the mpox outbreak. 8In Brazil, 10,904 confirmed mpox notifications had been registered by Epidemiological Week (EW) 16 of 2023, 9 of which 1,039 (9.5%) notifications related to confirmed cases in the city of Rio de Janeiro. 10 The scientif ic literature on mpox is still scarce. 11In the same way as other endemic diseases on the African and South American continents, this health problem has been neglected, gaining repercussion and research funding only after the occurrence of cases in the Northern Hemisphere, revealing the colonial perspective in scientific practice. 12The importance of understanding the manifestation of the disease in the population is highlighted, so as to contribute to building health actions.As such, the objective of this article was to describe the sociodemographic and clinical characteristics of reported mpox cases among residents of the city of Rio de Janeiro.

Design and data source
This was a descriptive study of mpox data reported to the Ministry of Health.The Research Electronic Data Capture (REDCap) tool was used to manage the database, which was structured, validated and managed by the Rio de Janeiro Municipal Health Department.

Study participants
The study included confirmed mpox cases among people resident in the city of Rio de Janeiro, Brazil, registered on the aforementioned platform from June 15, 2022 -date of the first mpox case notified in the city of Rio de Janeiro -until November 7, 2022, the closing date for notifications input to REDCap.

Context
This study used case definitions according to risk communications about mpox issued by the Rio de Janeiro Strategic Health Surveillance Information Coordination Service (Coordenação de Informação Estratégica em Vigilância em Saúde) in the city of Rio de Janeiro, adapted from Ministry of Health definitions (Supplementary Box 1).A suspect case is considered to be an individual of any age who, with effect from March 15 2022, has sudden onset of acute skin rash suggestive of mpox, either single or multiple, on any part of their body (including the genital region), whether or not associated with adenomegaly or report of fever.A confirmed mpox case is an individual who meets the suspect case definition and has a "positive/detectable" mpox laboratory test result/report obtained by means of molecular diagnosis (real-time PCR and/or sequencing).
Programmatic areas were taken as the unit of analysis regarding place of residence.The city of Rio de Janeiro is divided into ten health programmatic areas, which are organized according to the city's administrative regions, which, in turn, are comprised of neighborhoods.The ten programmatic areas are distributed in the Central region (programmatic area 1.0), South Zone (programmatic area 2.1), North Zone (programmatic areas 3.1, 3.2 and 3.3) and West Zone (programmatic areas 4.0, 5.1, 5.2 and 5.3) of the city (Figure 1).

ORIGINAL ARTICLE
Notified cases of mpox in the city of Rio de Janeiro, Brazil The estimated population of the city of Rio de Janeiro was obtained from the population projection for the year 2022 made available by the Instituto Pereira Passos. 13The populations of the administrative regions were grouped into the ten programmatic areas of the city of Rio de Janeiro, and were then used as a denominator to calculate the mpox incidence rates for each territory.After calculation, these data were plotted in order to visualize the spatial distribution of mpox rates in the city of Rio de Janeiro in the period analyzed.

Data analysis
Descriptive statistical analyses of the demographic, socioeconomic and clinical data of confirmed cases of mpox were performed out using R software version 4.2.1, and measures of central tendency and dispersion of continuous variables and f requencies of categorical variables were calculated.
QGIS software version 3.18.1 "Zürich" was used to describe the spatial distribution of incidence rates, whereby analyses were performed according to the programmatic areas, through shapef iles made available by the Instituto Brasileiro de Geografia e Estatística 14 and by the Instituto Pereira Passos. 15

Data quality control
Database records underwent quality control to eliminate any duplicate records or to modify records with inconsistent data.

RESULTS
All 928 confirmed cases of mpox resident in the city of Rio de Janeiro notified during the study period were included.The onset of symptoms of the first case occurred in EW 24 of 2022, and the peak in cases can be seen in EW 30 of 2022 (Figure 2).
There were no pregnant women in the sample and the majority of cases (98.8%) were of Brazilian nationality.Of the 11 foreigners, 5 were Argentinian, 2 were Colombian, 2 were French, 1 was from Bolivia and 1 was from Peru.
Among the notif ied cases, 34.5% had immunosuppression due to diseases, 41.9% reported being HIV positive, 13.2% reported having some other active sexually transmitted infection at the time of care, and of these, 85.2% had active syphilis at the time of mpox notification (laboratory confirmed) (Table 2).The most common mpox signs and symptoms were: lesion in genital/perianal/oral skin tissue/ mucous membrane (96.6%),fever (58.3%), adenomegaly (43.3%), headache (38.7%).Lesions predominated in multiple sites on the body (67.8%), the most common being in the genital region (46.1%).The main form of transmission, assumed based on the information contained in the notif ication, was person-to-person (33.0%), followed by sexual transmission (19.2%).No hospitalization occurred in the majority of   (25.8%), followed by programmatic area 4.0 (17.2) and programmatic area 1.0 (14.0%) (Table 3).
Regarding the incidence rate, the highest rate was found in programmatic area 1.0, with 43 cases per 100,000 inhab., followed by programmatic area 2.1 and programmatic area 2.2, with 39 and 21 cases per 100,000 inhab., respectively (Figure 1).

DISCUSSION
This study described the profile of confirmed cases of mpox living in the city of Rio de Janeiro, which occurred, for the most part, among This study has some limitations.During this analysis period, the notification form was updated three times, resulting in changes and updates to variables, including new mandatory fields.This generated gaps in the initial forms.Furthermore the difficulty of migrating and integrating data, together with changes to the notification form, led to some information being incomplete.
][19][20] It is essential to highlight that the disease is not exclusive to a certain gender or sexual orientation, and this reflection must be emphasized to combat any stigma that may be associated with the population most at risk.When comparing the results of this research with data for Brazil as a whole, 21 it is possible to corroborate the trends found, with a peak in cases between EWs 30-31, followed by a drop in the occurrence of the disease.The epidemiological and clinical profile observed in the city of Rio de Janeiro was also similar to the national one, with higher incidence in cisgender men, of White race/skin color, in the 30 years age group, presenting mild symptoms and with good case progression. 21veral f indings of this study are in line with the clinical characteristics described by the WHO.  It  important to highlight that although the occurrence of multiple lesions is the most frequent clinical characteristic, 17 many people infected by the virus may be

ORIGINAL ARTICLE
Notified cases of mpox in the city of Rio de Janeiro, Brazil asymptomatic. 24Although the cases were predominantly mild, it is important to highlight the high prevalence of risk factors for severity.
We found a high percentage of people with positive HIV serology, and mpox and HIV co-infection could explain a possible greater severity of clinical manifestations, although this was not found in our sample. 25It is possible that the severity of the cases was low due to the timeliness of case diagnosis and treatment.
We found higher incidence of cases in central areas with greater purchasing power in the city of Rio de Janeiro (programmatic areas 1.0 and 2.1).These areas are characterized by the presence of leisure facilities and concert halls, in addition to being the territories most visited by tourists who come to the city of Rio de Janeiro. 26hese factors may provide more opportunities for prolonged contact between individuals, as well as increasing the likelihood of interaction with people from other countries or regions where the virus is circulating.
Public hospitals and health centers made most case notif ications and, more than a reflection of the severity or socioeconomic profile of the cases, this distribution may be linked to the referral strategy adopted by the public health authorities in the city of Rio de Janeiro.As the mpox outbreak was a Public Health Emergency of International Concern, the city concentrated attention on the first cases at a reference unit for infectious disease clinical research, teaching, referral services and care, this being a fact that facilitated the care and surveillance services to achieve timely epidemiological investigation and case monitoring.
Around 1% of mpox cases in the world were residents of the city of Rio de Janeiro, 5 which accounted for 74% of cases in the state of Rio de Janeiro 16 and 9% of cases in Brazil. 9Although there were no deaths among residents of the city of Rio de Janeiro, Brazil was the country with the second highest absolute number of deaths 5 and the state of Rio de Janeiro had the highest number of deaths in Brazil. 9nsidering the epidemiological panorama of mpox infection in Brazil, 9 despite the decreasing trend in the world, 5 the United States Centers for Disease Control and Prevention stressed the importance of monitoring and preventive interventions among people living with HIV due to the serious manifestations in this population group.This guidance was given in view of the frequency of deaths and the greater occurrence of morbidity and mortality among people living with HIV, specifically those with CD4+ T lymphocyte counts < 200 cells. 27s such, in March 2023, the Ministry of Health began its pre-exposure vaccination campaign in Brazil against mpox aimed at this population using the immunizing agent MVA-BN Jynneos mpox. 3,5At an individual level, vaccination should not replace other known protective measures. 27is study is the first to analyze the profile of mpox cases in the city of Rio de Janeiro, contributing to a better understanding of this problem in the population and providing support for effective health actions.Case management also reflects the central and fundamental role of Health Surveillance in the city of Rio de Janeiro, with emphasis on the Rapid Response Unit teams of the Strategic Health Surveillance Information Coordination Service, which allowed detection and timely notification of cases, enabling the implementation of control actions, such as contact tracing, isolation and monitoring of individuals until the cases were closed.This study also helps to highlight the importance of investing in Health Surveillance as an essential tool for responding to public health emergencies, fundamental in advancing the field of public health, as well as highlighting the need for additional investigations and studies to continue tackling this health problem.

I n co n cl u s i o n , t h i s s t u d y o f fe re d a comprehensive analysis of the profile of mpox
rates in the city of Rio de Janeiro Programmatic Areas of the City cases/100,000 inhab.cases/100,000 inhab.cases/100,000 inhab.cases/100,000 inhab.State of Rio de Janeiro Brazil BRAZIL .

Figure 1 -
Figure 1 -Distribution of mpox rates per programmatic area of residence of cases in the city of Rio de Janeiro, from June to November 2022 (n = 928)

Figure 2 -
Figure 2 -Distribution of mpox virus cases in the city of Rio de Janeiro by epidemiological week of onset of symptoms, from June to November 2022 (n = 928)

Table 2 -Confirmed mpox cases resident in the city of Rio de Janeiro, according to self-reported clinical manifestations, from June to November 2022 (n = 928)
a) Variable accepted more than one category as an answer; b) Excludes vertical transmission, sexual transmission or transmission associated with health care.

Table 1 -Other signs and symptoms of confirmed mpox cases resident in the city of Rio de Janeiro, from June to November 2022 (n = 928) Signs and Symptoms a N %
a) An individual could report more than one sign/symptom occurring in the 21 days prior to the medical consultation.